Toradol (Ketorolac) given to pt w/ known renal failure

[Wombat's Gal]

What is the name of your state? North Dakota.

Pt (male, 31) w/ well-documented but stable hx of CHF, CRF (creatinine fluctuated between 1.9 and 2.3 during 12 months pre-op) and Type 1 diabetes was given Toradol (ketorolac) post-op after recent pacemaker surgery; suffered acute renal failure as a result (creatinine 4.0, potassium 8.1), was discharged as "stable" after 36 hours but died three days later at home.

Doctor actually said "oops" after seeing Toradol had been ordered and administered, despite the drug being contraindicated in a patient with heart failure and/or renal failure.

Do we - his family - have any legal recourse regarding this error?

 

[xylene]

The prescribing information lists renal impairment as a use with caution, not a contraindication. This is the case with all NSAIDs.

You should consult a med-mal attorney for your own peace of mind and to see if this violated the standard of care or was in an way actionable.

Was an autopsy performed?

What was the patients BMI?

I'm sorry for your loss. Best wishes in your families' emotional recovery.

 

[Wombat's Gal]

Pt's BMI was 23 +/-.

We'd gone through the prescribing information, and according to the hospital in question, Toradol is actually "generally contraindicated in patients with CHF (EF < 30%) and/or coexisting CRF", though I'm not sure how much - if any - validation this gives to the situation.

(His EF was last measured at 20%, in October 07)

Thank you so much for your help so far.

Edit: No autopsy was performed (which surprised me, actually)

 

[ecmst12]

I'm going to wait for the medical professionals to comment, but if the medication directly led to his death, and the doctor admitted it was a mistake to administer it, it's probably at least worth looking into.

However, EF of 20% is very low; patient was very sick to begin with (even if he was stable) and that will make the case more difficult.

 

[lealea1005]

What is the name of your state? North Dakota.

Pt (male, 31) w/ well-documented but stable hx of CHF, CRF (creatinine fluctuated between 1.9 and 2.3 during 12 months pre-op) and Type 1 diabetes was given Toradol (ketorolac) post-op after recent pacemaker surgery; suffered acute renal failure as a result (creatinine 4.0, potassium 8.1), was discharged as "stable" after 36 hours but died three days later at home.

Doctor actually said "oops" after seeing Toradol had been ordered and administered, despite the drug being contraindicated in a patient with heart failure and/or renal failure.

Do we - his family - have any legal recourse regarding this error?

I'm sorry for your loss.

What other prescibed medication was he taking at the time?

Edit to add: For a young person, this gentleman had a myriad of medical issues. It is questionable whether the Toradol, given in recommended doasage for the short period he would have received it, would be the lone reason for his renal failure.

 

[Wombat's Gal]

List of meds, which pt had been taking for at least six months:

Lasix
Amiodarone
Lisinopril
Coreg CR
Imdur
Zocor
Celexa
Aspirin
Lantus
Novolog
Lortab and Xanax (for three days only)

(I think that's everything - I was his primary caregiver)

We know that Toradol can reduce the effects of Lasix, and that there may be several other interactions though as has been mentioned, pt had serious health problems.

Having said that, he was stable - even with such a low EF - until the Toradol was administered post-surgically.

The current "popular opinion" (of both the treating physician and the pt representative) seems to be that acute renal failure and fluid overload caused or aggravated by the Toradol contributed to worsening symptoms of the heart failure, leading to a terminal event...the irony being that his pacemaker worked fine (as was confirmed by attending paramedic).

Many thanks for responses so far.

 

[seniorjudge]

You really need a second medical opinion; this is a very touchy situation and the answers are not clear.

 

[lya]

This patient's death is not going to be attributed to the administration of Toradol.

Keep in mind that the patient recovered from the renal problem and was discharged home.

Remember the patient had anesthesia for the pacemaker insertion and patients with EJ less than 20% do not metabolize and excrete anesthesia effectively. Who's to say it was the anesthesia and not the Toradol?

Look at the medications the patient was on; look at the cardiac myopathy of an ejection fraction of less than 20%. An ejection fraction of that level will not sustain life.

All that was keeping this patient alive was the medications, a modified lifestyle, and the will to live.

There is no way a medical expert will opine that only the administration of Toradol caused the patient's death.

On this forum, consulting with a medmal attorney is always the correct answer. It's better to hear "yes" or "no" from an attorney familiar with the claim.

 

[Wombat's Gal]

Pt did not have general anesthesia; as is generally the case, pt was sedated but conscious throughout pacemaker insertion. Thus, anesthesia was (obviously) not causative, as none was used.

Although pt was indeed very sick, his cardiomyopathy (even with reduced EF) was not considered life-threatening at that point (this from his medical team, not my own interpretation). It could be argued that without insulin, his chronic diabetes could also not sustain life - I'm not entirely sure what you're getting at, with all due respect?

As a sidenote, I'm curious as to North Dakota's laws/requirements relating to mandatory autopsy....any clues? (I realise I'm sidetracking - not intentionally hijacking though!).

Many thanks.

 

[lya]

Conscious sedation is anesthesia, though not general anesthesia, and requires being metabolized and excreted just as does any other medication.

Yes; type 1 diabetes would "kill" if insulin were not taken. EF < 20% will "kill" if not supported by medications and a modified lifestyle because the heart cannot pump efficiently enough for the kidneys and other vital organs to function at a level that will support life, and we're not talking minute to minute having a heartbeat but are talking about staying alive.

The patient had a pacemaker because the patient's heart had one or more consistently occurring rhythms that would not support life.

The patient was taking Amiodarone, which means the patient had a history of a rapid heart rhythm that would not support life.

I would expect the pacemaker to also be a defibrillator.

Medical malpractice requires an act of negligence that is THE cause of the outcome, in this situation, the patient's death.

We start looking at this claim by evaluating the patient at the time of the claimed negligent event.
--The patient was in poor health, with a complicated, longterm history of comorbidities:
--a weakened and ineffective heart that frequently changes from a normal rhythm to various rhythms requiring medication regimens and an implanted pacemaker
--damaged kidneys from multiple possible causes (heart, diabetes, coronary artery disease)
--hyperlipidemia
--hypertension
--angina
--depression
--pain
--anxiety

To have a valid and viable claim of medical malpractice that resulted in the patient's death, you would have to prove that none of the above was the cause of death.

It can't be done.

Looking at the above information in the presence of a death 3 days after pacemaker insertion and Toradol administration, negligence does not jump to the forefront of "what could have happened". In fact, death of the patient is not a surprise or unexpected finding. (this does not mean that the family was not shocked or that the doctor(s) was somewhat surprised at the timing, especially since the MD had just performed what he/she thought was a procedure that would prolong life)

I know you are shocked and in grief and looking for some way to make sense out of the death of your loved one. It is a normal reaction. It does not make a nonvalid claim of wrongful death change into a valid claim of wrongful death.

Consult with a medmal attorney; you'll find out that what I told you is true.

 

[Wombat's Gal]

You're right, Lya, in that it would be difficult (if not impossible) to prove that the Toradol caused the fatal event/s.

Having said that, I've actually been contacted by two different lawfirms who actually want to pursue the issue!

Yes, we're all still quite in shock, and I realise that doing so would not bring Rob back, and to be perfectly frank it's not a route I particularly want to take anyway - perhaps this is something his surviving parents wish to pursue.

Many thanks for your (and all other) responses.

Take care.

 

[Wombat's Gal]

An update

After receiving correspondence from a MedMal attorney, the hospital has apparently offered our dear one's parents (who are legally next of kin) a settlement after admitting some liability (regarding the administration of the Toradol), despite there being no autopsy.

I have a feeling it's a "good faith" decision, as opposed to anything else, but wanted to give a quick update.

Thank you for the helpful responses, and though it doesn't bring our dear one back, his parents at least can perhaps use this to bring some sort of closure.

 

[barry1817]

settlement

After receiving correspondence from a MedMal attorney, the hospital has apparently offered our dear one's parents (who are legally next of kin) a settlement after admitting some liability (regarding the administration of the Toradol), despite there being no autopsy.

I have a feeling it's a "good faith" decision, as opposed to anything else, but wanted to give a quick update.

Thank you for the helpful responses, and though it doesn't bring our dear one back, his parents at least can perhaps use this to bring some sort of closure.

I am always under the impression that there are two types of settlements. One is a settlement to avoid trial and to avoid a larger liability award that a jury might give. The other is a nuisance settlement to make a party go away. I have no idea what your settlement would have been. I hope that it wasn't a nuisance settlement that they gave.

 

[Wombat's Gal]

Likewise, I have no idea either.

It wasn't my settlement; this was merely a courtesy "update" doodad.